[Mechanical complications of myocardial infarction in elderly patients]

As mechanical complications after myocardial infarction in the elderly, we described the therapeutic strategies for postinfarction ventricular septal perforation (PVSP), ischemic cardiomyopathy (ICM), and ischemic mitral regurgitation (IMR). To improve operative results for PVSP in the elderly, it is important to maintain hemodynamics by cardiac support device such as intraaortic balloon pumping, and to perform prompt surgical intervention before cardiogenic shock and multiple organ failure. Infarct exclusion technique is a standard surgery for PVSP. Both ICM and IMR are common disease caused by severe cardiac ischemia and mitral valve (MV) function is related to left ventricular (LV) geometry. We consider total MV-LV geometrical repair by LV restoration surgery, MV repair, and coronary revascularization is essential to improve morphological abnormality in LV and MV even in the elderly. To maximize LV function, septal anterior ventricular exclusion (SAVE) technique for antero-septal myocardial ischemia, apex-sparing Batista operation for lateral ischemia, and undersized mitral annuluoplasty to improve LV sphericity are procedures of choice. However, it is still difficult to save elderly patients with very low cardiac function. Novel treatments such as regenerative medicine by angiogenic cytokines and/or cell transplantation, and advanced medical treatments are waited for this high-risk group.

Toward the best treatment for uncomplicated patients with type B acute aortic dissection: A consideration for sound surgical indication

BACKGROUND

In the treatment of type B acute aortic dissection without complications, better results are obtained if surgery is performed before enlargement of the aorta in patients who are predicted to show aortic enlargement and if drug-based treatment is continued for patients who are predicted to show no enlargement. The purpose of this study was to predict the acute-phase factors that may affect chronic-phase aortic enlargement by studying chronic-phase enlargement of dissections in patients without complications during the acute phase.

METHODS AND RESULTS

In 101 patients with type B acute dissection who had no complications, univariate and multivariate factor analyses were performed to determine the predictors for chronic-phase enlargement (>/=60 mm) of the dissected aorta. The independent predominant predictors for aortic enlargement in the chronic phase were a maximum aortic diameter of >/=40 mm and a patent false lumen during the acute phase. The values of actuarial freedom from aortic enlargement for the patients with a maximum aortic diameter of 40 mm and a patent false lumen at 1, 5, and 10 years were 43%, 33%, and 22%, respectively, whereas in patients with a maximum aortic diameter of <40 mm and a closed false lumen, the values were 97%, 94%, and 84%, respectively.

CONCLUSIONS

These results suggest that patients with type B acute aortic dissection who show a maximum aortic diameter of >/=40 mm and a patent false lumen should undergo surgery earlier during the chronic phase before enlargement of aorta, whereas patients with a maximum aortic diameter of <40 mm and a closed false lumen should continue to receive hypotensive therapy.

Acute dissection of the abdominal aorta

A 64-year-old man presented with sudden lower abdominal pain and diffuse lumbago. He was diagnosed as having primary dissection of the abdominal aorta. Entry closure and aneurysmal wall plication was performed, and the subsequent course was satisfactory. Surgical intervention is recommended for patients with abdominal aortic dissection in the infrarenal segment, where the extent of dissection is limited and access is comparatively easy. Enhanced computed tomography is useful both in diagnosis and follow-up of this aortic disease.

Experience with emergency cardiac surgery following institution of percutaneous cardiopulmonary support

Between August 1992 and February 1998, 43 patients were treated with percutaneous cardiopulmonary support (PCPS) in our institution, and 8 of them subsequently required emergency cardiac surgery. There were 3 males and 5 females with a mean age of 63 years (range, 37 to 81 years). The etiology of shock in these 8 patients was acute myocardial infarction in 3, postinfarction left ventricular (LV) free wall rupture in 1, postinfarction ventricular septal perforation (VSP) in 1, LV free wall rupture and VSP in 1, and fatal arrhythmia due to severe aortic valvular disease in 2. The mean time interval from the onset of cardiogenic shock to the institution of PCPS was 77 min (range, 18 to 183 min). The mean time interval from the institution of PCPS until surgery was 145 min (range, 40 to 603 min). The surgical procedures were coronary artery bypass grafting (CABG) in 3 patients, closure of the LV rupture and/or closure of VSP in 3, and aortic valve replacement in 2. Six patients were weaned from PCPS, and 2 patients were discharged from the hospital (discharge rate, 25%). Although the results of emergency cardiac surgery following PCPS still are not satisfactory, we continue to apply PCPS and perform appropriate surgical procedures to improve the survival rate of the patients who would die without PCPS.

Serum levels of soluble intercellular adhesion molecule-1 and soluble vascular cell adhesion molecule-1 in asymptomatic carriers of hepatitis C virus

High levels of serum-soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) have been noted in patients with chronic hepatitis C. This study aimed to measure serum levels of sICAM-1 and sVCAM-1 in asymptomatic hepatitis C virus carriers and clarify the clinical significance of measuring soluble forms. Serum levels of sICAM-1 were significantly higher than in healthy controls but serum sVCAM-1 levels did not differ statistically from those in healthy controls. Liver biopsy obtained from 12 asymptomatic hepatitis C virus carriers showed evidence of hepatitis. Estimating sICAM-1 and sVCAM-1 in asymptomatic carriers may be helpful, especially in cases in which liver biopsy is not possible.

[Preoperative magnetic resonance angiography findings and postoperative neurological complications in 93 cases of CABG with cardiopulmonary bypass]

Between February 1994 and January 1997, 102 of the 146 patients treated by coronary artery bypass grafting (CABG) had undergone magnetic resonance angiography (MRA) of the brain and neck before the operation, and arterial stenosis or occlusion had been detected in 38 (36.9%) of them. Two of these patients had complicating severe calcification of the ascending aorta, and CABG was performed without cardiopulmonary bypass (CPB). Seven patients without stenotic lesions on MRA were also treated by CABG without CPB for other complications. In addition to the 102 patients one patient had been found to have occlusion of the left common carotid artery and poor enhancement of the distal portion, and as a result we switched from CABG to percutaneous transluminal angioplasty (PTCA). We enrolled 93 patients in this study excluding these 10 patients. The patients were distributed into the three groups according to the MRA findings. Group C = no stenotic lesions (58 patients). Group S = stenosis of < 70% (26 patients), Group SS = stenosis of > or = 70% (9 patients). Enhancement distal to the stenotic or occlusive lesions was good in all patients in group S and SS. We then examined them for the incidence of postoperative neurological complications. There were no significant differences among the three groups in regard to age, male/female ratio, or incidence of hypertension and hyperlipidemia. In Group S, the incidence of diabetes was significantly higher than in the other Groups. The incidence of prior stroke was significantly higher and the number of coronary arteries affected was significantly larger in group SS than the other groups. There were no significant differences among the three groups with regard to intraoperative variables. The lowest mean arterial pressure on CPB was 44.3 +/- 7.4 mmHg, 48.0 +/- 8.8 mmHg, 46.3 +/- 7.8 mmHg in Group C, S, and SS, respectively, In all groups the lowest mean arterial pressure on CPB was below 50 mmHg. There were no significant differences among the three groups with regard to time to awaken and time to extubation. Two patients experienced transient conciousness disturbance after CABG, one in Group C, the other in Group SS, but no new lesions were detected by brain CT. Only one patient, in Group C. suffered a stroke and had a new lesion on brain CT a month after the operation. No strokes occurred in the perioperative period. In nine patients with good enhancement distal to the severe stenotic or occlusive lesion on MRA of the brain and neck the lowest mean arterial pressure on CPB was below 50 mmHg, but there was no postoperative neurological complications due to the low perfusion pressure on CPB. The results of this study suggested that CABG with CPB can be performed safely in patients with good enhancement distal to the stenotic or occlusive lesions on MRA of the brain and neck.

[Successful emergency coronary artery bypass grafting after use of a percutaneous cardiopulmonary support system in a patient with cardiopulmonary arrest secondary to acute myocardial infarction]

A 37-year-old woman was taken to a hospital because of sudden chest pain. She lapsed into shock, and the ECG indicated acute myocardial infarction. The ECG later showed ventricular fibrillation, and the patient was given cardiac massage while being transported to our hospital, where she was resuscitated with a percutaneous cardiopulmonary support system. Emergency coronary angiography revealed 99% stenosis of the left main coronary artery. PTCA was performed, and the stenotic lesion was released, but dissection and rapid formation of a thrombus were detected in the LAD. Re-PTCA was performed, but the hemodynamics did not improve, and emergency CABG of the LAD, D1, and LCx was performed. Postoperative max CPK was 18,957 IU/L. Although postoperative MRSA pneumonia developed as a complication, weaning from the respirator was performed 17 days after the operation. The patient was discharged, ambulatory, 74 days after the operation.

[Early hemodynamic effects of olprinone hydrochloride after coronary artery bypass grafting]

Our purpose was to evaluate the hemodynamic effects of olprinone hydrochloride early after coronary artery bypass grafting (CABG). Fifteen patients undergoing CABG were administered a constant infusion of 0.1 microgram/kg/min of olprinone and continued for 4 hours. No bolus infusion of olprinone was administered before continuous infusion. Systolic systemic arterial pressure, systolic pulmonary arterial pressure, systemic vascular resistance and pulmonary vascular resistance were significantly decreased. There were no significant changes in heart rate, mean central venous pressure, mean left atrial pressure and left ventricular stroke work index. Cardiac index was significantly increased, but a correlation between cardiac index and mixed venous blood oxygen saturation was not found. Double product was significantly decreased, which described above suggest that olprinone achieved improvement of left cardiac function without more myocardial oxygen consumption. Severe transient hypotension (systolic arterial pressure < 80 mmHg) after infusion of olprinone was observed in three patients. Olprinone administered soon after CABG surgery had beneficial effects in terms of improvement of hemodynamic status without more oxygen consumption and reduction of pulmonary vascular resistance. However transient hypotension was a serious clinical problem in patients after open heart surgery, especially in CABG patients who need suitable systolic arterial pressure to keep enough blood perfusion of arterial bypass grafts.

Isolated tricuspid regurgitation caused by a dilated tricuspid annulus

In most of the previously reported cases of isolated tricuspid regurgitation, both tricuspid leaflets and subvalvar tissue have been absent, hypoplastic, or fused. For this reason, tricuspid valvoplasty was difficult and valve replacement was adopted in many cases. In the present case of a 52-year-old man, however, the tricuspid valve showed no abnormalities other than a severely dilated tricuspid annulus. Ring annuloplasty was performed, and this resulted in a subsequent satisfactory course without anticoagulant therapy.

[An emergency aortic valve replacement for cardiogenic shock patient with severe aortic stenosis and regurgitation using percutaneous cardiopulmonary support]

The percutaneous cardiopulmonary support system (PCPS) was used in a 64-year-old woman with cardiogenic shock due to sustained ventricular fibrillation (Vf) caused by severe aortic stenosis and regurgitation. The Vf attack was resistant to cardioversion and adrenaline for lack of left ventricular support by PCPS. She was transported to the operation theater with PCPS in situ and emergency aortic valve replacement was performed. Although preoperative cardiac resuscitation time was long (35 minutes), she was discharged from the hospital on foot without any neurological complications on 84th postoperative day. Because PCPS does not decrease left ventricular systolic stress in poorly contracting dilated heart, early surgical treatment is needed in patients with severely damaged heart.

Enteropathogenic bacteria in the La Paz River of Bolivia

Diarrheal diseases often result from ingestion of contaminated water or food. The population of La Paz, Bolivia is directly or indirectly exposed to the sewage-contaminated La Paz River. We conducted a bacteriologic survey of the La Paz River to quantify the level of bacterial contamination, with particular reference to enteropathogens. A total bacterial count exceeding 10(6) colony-forming units (CFU)/ml, including lactose fermenting and nonfermenting, gram-negative bacilli of approximately 10(5) CFU/ml, respectively, were detected in river water samples collected near two densely populated areas. A total bacterial count of 10(5) CFU/ml was also detected at the most downstream area of the river near a sparsely populated area. At four sampling locations, several enteropathogens were detected, including five enterotoxigenic Escherichia coli (ETEC) (serotype O6, O15, and O159), two enteropathogenic E. coli (EPEC) (serotype O44), two enteroinvasive E. coli (EIEC) (serotype O29), and three Salmonella O4 group isolates. The heat-labile enterotoxin gene and the invasive toxin gene were detected in all ETEC and EIEC isolates by polymerase chain reaction analysis. Nine isolates of E. coli were found by the agar dilution method to be susceptible to ampicillin, kanamycin, nalidixic acid, tetracycline, and chloramphenicol, and ampicillin resistance was found in only two isolates of EIEC 7-4 (serotype O29) and EPEC 7-5 (serotype O44). Ampicillin resistance was coded on plasmids and transferred conjugatively to E. coli chi1037 at a frequency of 10(-5) CFU/donor by the broth mating method. Strains of Aeromonas caviae, which can cause diarrheal disease in infants, were detected in vegetables grown in fields irrigated by water from the La Paz River. The survival of nine isolates of E. coli in filtered river water was compared with that of laboratory strains (E. coli chi1037, W3110, and ATCC29577). The survival time of seven isolates, excluding two ampicillin-resistant isolates, was markedly longer than that of the laboratory strains. Our results show a high bacterial contamination of the La Paz river and suggest that such levels may contribute to the high incidence of diarrheal disease in the city of La Paz.

[Anomalous origin of the right pulmonary artery from the ascending aorta--a report of three operative cases]

Three patients with anomalous origin of the right pulmonary artery from the ascending aorta were reported. Case 1: A 33-day-old premature infant (body weight 984 g) with the right pulmonary artery arising from the ascending aorta (RAPAA) and the patent ductus arteriosus (PDA). Banding of the right pulmonary artery (RPAB) and ligation of PDA were performed as a palliative operation. AT 3-month-old (BW 2,200 g), division and direct anastomosis of the anomalous vessel to the main pulmonary trunk was done as a radical operation under hypothermic cardiopulmonary bypass (CPB). Case 2: A 16-day-old infant with RAPAA and PDA. Division and direct anastomosis of the anomalous vessel to the main pulmonary trunk and ligation of PDA were performed as a radical operation under hypothermic CPB. Case 3: A 74-day-old infant with RAPAA and Ebstein's anomaly. RPAB was performed as a first palliative operation and left Blalock-Taussig shunt as a second operation. Glenn operation is scheduled as third operation prior to Fontan type operation.

[Successful surgical treatment of double-outlet right ventricle with intramural coronary artery, using the modified Aubert procedure--a case report]

The modified Aubert procedure and left ventricular outflow tract reconstruction were performed successfully for double-outleft right ventricle with subpulmonary ventricular septal defect, which showed an unusual Shaher type 5a coronary artery pattern. This pattern was characterized by two coronary ostia arising from the right septal sinus and intramural segment in a left trunk of the coronary artery. In this case, the neo-pulmonary artery was reconstructed without prosthetic materials. However, postoperative echocardiography showed no evident supravalvar pulmonary stenosis. The modified Aubert procedure without prosthetic marerids can be used for double-outlet right ventricle and transposition of the great arteries which show dilated prelimonary artery.

Serum levels of soluble intercellular adhesion molecule-1 and soluble vascular cell adhesion molecule-1 in liver disease, and their changes by treatment with interferon

Serum levels of soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) were measured by an enzyme-linked immunosorbent assay in patients with chronic hepatitis (n = 57), liver cirrhosis (n = 19) and hepatocellular carcinoma (n = 33). Serum levels of sICAM-1 and sVCAM-1 were significantly higher in liver disease than those in controls (P < 0.0001 and P < 0.0005, respectively). A total of 22 patients with chronic hepatitis C were treated with interferon. Pretreatment levels of sICAM-1 and sVCAM-1 were not significantly different between complete responders and non-responders. In complete responders, serum sICAM-1 and sVCAM-1 levels 1 year after interferon treatment significantly decreased compared to the pretreatment levels (P < 0.005 and P < 0.05, respectively). Post-treatment levels of sICAM-1 and sVCAM-1 in complete responders were also significantly lower than those in non-responders (P < 0.005 and P < 0.05, respectively). This suggests that monitoring soluble adhesion molecules might be useful in the follow-up of patients with liver disease.

Idiopathic adulthood ductopenia

In 1981, a 26 year old man occasionally demonstrated elevated serum transaminase concentrations. He had no history of medication, or a personal or family history of jaundice, except for prolonged physiological jaundice as a neonate. Serum hepatitis B surface antigen, hepatitis C virus antibody and anti-mitochondrial antibody were absent. A wedge biopsy specimen revealed ductular proliferation, mild inflammation of the portal area and disappearance of bile ducts from 80% of the portal tracts. Serial sections demonstrated a vanishing bile duct. Endoscopic retrograde choledochopancreatography, portography and arteriography demonstrated no abnormalities. In 1994, the patient died of hepatic failure following a 12 year observation period. He was subsequently diagnosed with idiopathic adulthood ductopenia on the basis of the criteria proposed by Ludwig.

Assessment of clinical significance of positive blood cultures of relatively low-virulence isolates

In Omori Hospital, Toho University School of Medicine, relatively low-virulence blood isolates, including coagulase-negative staphylococci (CNS), enterococci and nonfermentative gram-negative rods other than Pseudomonas aeruginosa comprised c. 60% of total blood isolates. A retrospective study was conducted to assess their clinical significance by reviewing a total of 91 hospital charts. The physicians' assessments of these positive blood cultures as recorded in the charts were classified into four categories--sepsis, possible sepsis, contamination and no comment. The episodes classified as sepsis accounted for 5.0-19.6%. These episodes were also evaluated by a graded clinical significance score based on multiple factors, including number of positive cultures and clinical signs. The scores for the 91 episodes covered a wide range from 1 to 9, indicating that both contaminants and causative organisms may have been involved. The episodes judged as sepsis or possible sepsis tended to have higher scores. The scores for the episodes associated with enterococci were also higher than those involving CNS or non-fermentative gram-negative rods. The scores for episodes associated with intravenous hyperalimentation catheters were higher than those not associated with the catheters.

[Early detection of primary liver cancer--diagnosis of small liver cancer by needle aspiration biopsy]

Small liver cancer is defined as a solitary hepatocellular carcinoma (HCC) with a diameter less than 2cm. To detect liver cancer as early as possible, patients with liver cirrhosis are screened by ultrasound scanning. Pathological diagnosis in needle aspiration biopsy materials is needed because of low positivity of imaging other than ultrasound scanning. Pathological features are different from those of classical hepatocellular carcinoma. Most of the small HCCs are characterized by the following features: (1) increased cellularity, (2) increased nucleus/cytoplasm ratio, (3) irregular thin trabecular pattern, (4) pseudoglandular or acinar structures, (5) increased staining affinity (eosinophilic/basophilic), (6) frequent fatty change, and (7) residue of the portal tract. Capsules of HCCs, 1-1.5 cm in diameter, are formed. Before the formation of capsules, cancerous cells show a replacing growth pattern. Two cases of small HCC are presented, and these characteristic features are explained.